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Received 10 April 2014; revised 10 May 2014; accepted 10 June 2014

ABSTRACT

Background: The comorbidity between chronic physical conditions and psychosocial
health consequences is becoming a research interest for researchers in the field.
The purpose of this study was to investigate the psychosocial health status of patients
diagnosed with chronic illnesses in Jordan. Methods: A cross sectional survey using
806 patients diagnosed with chronic illnesses has been used to collect data in regards
to depressive symptoms, psychological distress, coping, optimism, life satisfaction,
and perceive social support. Results: 17.5% of the patients reported that they had
moderate to severe depressive symptoms, and about 50% of them had high level of
optimism and life satisfaction, moderate level of effectiveness of coping skills,
psychological distress, and perceived social support from family, friends and others.
There were significant association between patients’ age and their scores on perception
of social support from family, friends and others, life satisfaction, and psychological
distress (p > 0.05). While, male and female patients were different in their depressive
symptoms (t = −2.57, p = 0.01), perceived social support from others (t =
−2.06, p = 0.04), and optimism (t = 2.29, p = 0.02). Also, patients had differences
in their depressive symptoms, perceived social support from friends, others and
friends, optimism, life satisfaction, and psychological distress related to their
medical diagnoses (p < 0.05). Conclusion: Patients with chronic illness are in need
for psychological care, and periodic psychological screening is one step toward
maintaining their psychological wellbeing.

Keywords:Psychosocial Health, Chronic Illnesses, Jordan

1. Introduction

Chronic diseases have assumed an increasingly important role in reforming health
research and interventions. Therefore, comorbidity between chronic physical conditions
and psychosocial health consequences such as depressive feelings, stress, adherence,
and psychosocial health concerns became common interest for health professional
and researchers. According to Doumit and Nasser [1]
, patients with chronic illnesses are overwhelmed with psychological stressors due
to requirement related to management of their illnesses. However, patients’ psychosocial
status may interfere with their ability to manage their needs independently that
may exacerbate their health condition [2] .
For example, patients with chronic illnesses may suffer unexplained symptoms, anxiety
and depressive feelings that delay their recovery and healing process [3][4] . Thus, patients
with chronic illnesses are struggling to manage their physical illnesses independently
and further overwhelmed with vulnerability to increased psychosocial co-morbidity
[2] .

The comorbidity of psychological problems with chronic illnesses raised the issue
of the impact of psychological disturbances on patients’ health condition. The literature
showed that the psychological difficulties and psychological follow up care have
been linked with increased morbidity, mortality, and expenditure of health services
[5][6] . Health
care professional may sacrifice psychological care and focus only on patients’ physiological
needs. This will negatively influence the disease prognosis resulting in poor treatment
outcomes and may increase mortality rate [7][8] . The impact of chronic illnesses on the bio-psycho-social
aspects of individual’s health and wellbeing cannot be interpreted solely in terms
of disease process, but also relates to difficulties of individuals’ adjustment
to their illnesses and the evolved changes of their lifestyle
[9][10] . Therefore, issues, for example,
related to coping, social support, stress, optimism, and life satisfaction are significant
in process of health-illness continuum. Number of previous studies showed that there
is a strong relationship between difficulties in coping mechanisms, perceived social
support and the development of anxiety and depression among patients with chronic
illnesses [11] . Indeed, the ability of patients
to adjust and control their life stressors is associated with better psychosocial
wellbeing [11] .

The issue of management of chronic illnesses has showed growing interest for policy
makers in the Arabian region and particularly in Jordan. However, the information
related to psychological status of patient with chronic illnesses is limited. There
is a need to explore the psychological and social wellbeing of those patients especially
with the increased cost and demands for health care services globally. This study
came to respond to these concerns and more to increase our knowledge in the field
of mental and psychological wellbeing of patient with chronic illnesses. Therefore,
the purpose of this study is to investigate the psychosocial health status of patients
with chronic illnesses in Jordan. The specific aims are:

 To determine the psychosocial health status of patients with chronic
illnesses in Jordan in regard to related to stress, depression, perceived social
support, coping, optimism, and life satisfaction.

 The difference of the identification is the psychosocial health status
of patients with chronic illnesses in Jordan in relation to selected demographic
and personal characteristics of age, gender, working status, and medical diagnosis.

2. Method

2.1. Design

A quantitative approach using cross-sectional, descriptive-correlational design
was used to examine the psychosocial health status of patients with chronic illnesses
in Jordan. Data was collected from patients diagnosed with diabetes mellitus-type-II,
Rheumatoid arthritis, CAD, cancer, and pulmonary diseases from the three health
care sectors in Jordan (governmental, educational and private). Information collected
in regards to stress, depression, perceived social support, coping, optimism, and
life satisfaction.

2.2. Sample and Settings

Patients diagnosed with diabetes mellitus-type-II, Rheumatoid arthritis, CAD, cancer,
and pulmonary diseases represented the population for this study. A convenience
sampling of 806 completed and retuned the questionnaire. The study targeted patients
attending primary, secondary and tertiary care units. Inclusion criteria include:
1) diagnosed with one of the following chronic illness for longer than 6 months:
diabetes mellitus-type-II, rheumatoid arthritis, CAD, cancer, and pulmonary diseases,
2) at age of 18 years or older, and 3) ability to read and write in Arabic. Exclusion
criteria included: no history of diagnosed mental or cognitive disorders.

2.3. Data Collection Procedure

Prior data collection, ethical approval obtained from the Faculty of Nursing at
the University of Jordan, and the targeted institutions. Data collected using self
report format. Patients who expressed interest to participation in the study were
approached by the researcher who explained the study and provided them with all
details and answered all their questions. Patients were asked to sign the consent
letter that included information related to the title of the study, its purpose,
its significance and a statement informing the participants that their privacy would
be protected by assuring them that their responses will be treated confidentially,
and information that reveal their identity will not be recorded. Also, they were
assured that the information will be used for the purpose of the study, and that
their participation is voluntary and they have the right to withdraw at any time
during the study and that their decision will not influence the quality of care
they receive. The whole package presented in Arabic language.

2.4. Instruments

The data collected using an Arabic version of self-reporting questionnaires. The
tools first translation into Arabic language by a research assistant and back translated
into English language another independent research assistant as described by Brislin
[12] . Pilot testing conducted using patients
(n = 25) requesting their appraisals for the appropriateness of the translation.

The Instruments were:

1. Perceived social support was measured by Multidimensional Scale of Perceived
Social Support [13] . This scale is 12-item self-reported
scale to assess the perception of social support adequacy from the family, friends,
and significant others such as health care team. Each item is measured using a 7-point
Likert scale ranging from 1 (very strongly disagree) to 7 (very strongly agree).
The higher the score is the higher the perceived social support. This scale had
good internal consistency for the scale as whole which was 0.88. In this study,
Cronbach’s Alpha for the subscales were 0.85 (Family), 0.79 (friends), and 0.75
(others).

2. The Beck Depression Inventory-II (BDI-II) [14]
was used to assess patients’ depressive symptoms, which contain items that measure
cognitive-affective symptoms and attitudes, impaired performance, and somatic symptoms
[14] . This instrument contains 21
questions answered on a four-point Likert scale in which 0 represents the absence
of symptoms and 3 represents an extreme problem. The total range of 0 to 63 and
standard cutoff points as follow: 0 - 13 indicates no or minimal symptom, 14 - 19
indicates mild symptoms, 20 - 28 indicates moderate symptoms, and 29 - 63 indicates
severe symptoms [14] . A score of
13 is the cutoff point indicating depression. The test-retest r was .88, and Cronbach’s
Alpha is 0.87 [14] . In this study,
Cronbach’s Alpha was 0.85.

3. Stress was measured using the brief form of Psychological Stress Measure
[15] . The original Psychological Stress Measure
(PSM) was designed using 49 items drawn from descriptors generated by focus groups
on stress. The scale is unifactorial in structure and maintains a test-retest stability
of 0.68 to 0.80 under apparently constant conditions. Patients checks the answer
that best indicates the degree to which each statement has applied to him/her recently
The responses made on a Likert scale and ranged from range from 1 (null) to 4 (much).
The higher the score in the scale reflect higher level of psychological stress.
In this study, Cronbach’s Alpha was 0.88.

4. Coping skills was measured using the abbreviated version of the COPE Inventory
[16] . Brief COPE is a 28 items scale measures
the ways individuals use to cope with stress in their life. Brief COPE is formed
of 14 domains (each consisted of 2 items) were responses ranged from 1 (I haven’t
been doing this at all) to 4 (I’ve been doing this a lot). The scale takes >10 minutes
to be completed. The scale has good internal inconsistency with Cronbach’s alpha
of 0.83 (Carver, 1990). In this study, Cronbach’s Alpha was 0.73.

5. Optimism was measured using the Life Orientation Test (LOT-R) [17] . The LOT-R is designed to measure optimisms by
assessing the generalized outcome expectancies of individuals. Each item is scaled
on a five point Likert scale. The responses ranges from strongly agree to strongly
disagree. The scoring is done by reversing the negative statement and then adding
all the responses together. Cronbach’s alpha for the scale was 0.76 and test-retest
was estimated at 0.79 [17] . In this study,
Cronbach’s Alpha was 0.81.

6. Life satisfaction was measured using the Satisfaction with Life Scale [18] . This is a general measure of life
satisfaction, which consisted of five statements. Participants were asked to rate
each statement according to the following seven-point scale: 1) strongly disagree,
2) disagree, 3) slightly disagree, 4) neither agree nor disagree, 5) slightly agree,
6) agree, and 7) strongly agree. The scores of the total scale ranges from 5 to
35 and interpreted as follow: from 31 - 35 (eextremely satisfied), from 26 - 30
(satisfied), from 21 - 25 (slightly satisfied), 20 (neutral), from 15 - 19 (slightly
dissatisfied), from 10 - 14 (dissatisfied), and 5 - 9 (extremely dissatisfied).
The test–retest reliability was estimated to be 0.87 [18]
. In this study, Cronbach’s Alpha was 0.78.

A total number of 806 patients completed the questionnaire (see
Table 1). Patients’ age ranged from 18 to 90 years, with mean of 51.5 (SD
= 15). About 54% (n = 436) of the patients there were male patients, while 45.9%

(n = 370) were females. In regard to marital status, the majority of them 73.8%
(n = 595) were married, while 5.2% (n = 42) were divorced, and 10.5% (n = 85) were
single, and 10.4% (n = 84) were widow. The analysis also showed that most of patients
(52%, n = 419) were not working, and 25.3% (n = 204) of them had a full time work,
also 15.3% (n = 123) had retired, where the least percent 7.4% (n = 60) of patients
had a part time work.

In regard to their medical diagnosis, the analysis showed that 28.6% (n = 230) of
the patients had diabetes mellitus type-II, 21.6% (n = 174) had cardiovascular disease,
14.6% (n = 118) had pulmonary diseases, 13.3% (n = 107) had rheumatoid arthritis,
and 11.4% (n = 92) had cancer. The analysis also showed that the majority (70.1%,
n = 565) of patients were not smoking, while 29.9% (n = 241) were active smokers.
Among those who smoke, 25% (n = 60) of them smoked more than 10 cigarettes per day.

3.2. Psychosocial Health Status

3.2.1. Depression

Regarding depressive symptoms, the analysis (see Table
2) showed that the patients had a mean score of 16.1 (SD = 10.2) with scores
ranging from 0 to 54. About 50% of the patients had a score of 16 or above. In regards
to level of depression, the analysis showed that 41.4% (n = 334) of the patients
found to have no or minimal depressive symptoms, while 31% (n = 250) had mild depressive
symptoms, 15.5% (n = 125) had moderate depressive symptoms, and 12.0% (n = 97) had
severe depressive symptoms. The analysis indicates that about 25% of the patients
are suffering from depressive symptoms compared to 41% with no to minimal depressive
symptom.

3.2.2. Optimisms

Regarding patients’ optimism perception using life orientation scale (see Table 2), the analysis showed that patients had a mean score
of 34.5 (SD = 5.9) with scores ranging from 10 to 50. Considering that the possible
range of score is 5 - 50, and that the analysis showed that 50% (n = 403) of the
patients had a score of 34 or above and 50% of them had a score between 32 and 38,
the results indicate that patients, in general, had high level of optimism.

3.2.3. Coping Skills

Regarding patients’ coping skills using brief COPE scale (see
Table 2), the analysis showed that patients had a mean score of 71.6 (SD
= 10.1) with scores ranging from 29 to 104. Considering that the possible range
of score is 28 - 112, and that the analysis showed that 50% (n = 403) of the patients
had a score of 71 or above and 50% of them had a score between 67 and 77, the results
indicate that patients, in general, had moderate of their ability to effectively
cope with their life situations.

3.2.4. Life Satisfaction

Regarding patients’ satisfaction about their life (see
Table 2), the analysis showed that patients had a mean score of 23.8 (SD
= 5.8) with scores ranging from 5 to 35. Considering that the possible range of
score is 5 - 35, and that the analysis showed that 50% (n = 403) of the patients
had a score of 25 or above and 50% of them had

a score between 21and 28, the results indicate that patients, in general, had high
level of satisfaction about their life.

3.3. Psychological Distress

Regarding patients’ psychological distress level (see Table
2), the analysis showed that patients had a mean score of 41.9 (SD = 11.7)
with scores ranging from 14 to 68. Considering that the possible range of score
is 9 - 72, and that the analysis showed that that 50% (n = 403) of the patients
had a score of 42 or above and 50% of them had a score between 33 and 51, the results
indicate that patients, in general, had moderate level of stress.

3.4. Perceived Social Support

Regarding patients’ perception of perceived social support (see
Table 2), the analysis showed that patients’ highest perception of perceived
social support was from others and family with mean scores of 22.7 (SD = 4.9) and
22.2 (SD = 4.8) respectively. However, patients had lower perception of social support
from friends with score of 18.4 (SD = 6.2). In general, perception of social support
from family, friends and other were at the moderate level give the possible range
of score for each subscale to be 4 - 28 and the median scores for all subscales
were almost equal and at the moderate to high level (23 - 26). The analysis is showing
the lowest level of perception was support from friends although the scores of seem
to be at the moderate level.

Regarding the relationship between selected demographic characteristic and psychosocial
factors, the analysis showed that there was a significant and positive correlation
between patients’ age and their perception of social support from family (r = 0.11,
p = 0.003) and others (r = 0.08, p = 0.04), and life satisfaction (r = 0.14, p <
0.001).while, there was a significant and negative correlation between patient’s
age and perceived social support from friends (r = −0.10, p = 0.004) and psychological
distress (r = −0.08, p = 0.03). The results indicate that that older patients
are more likely to have higher level of support from friends and others, and life
satisfaction, and lower level of support from friends and higher level of psychological
distress.

Regarding gender differences, the analysis showed that there was significant difference
between male and female patients in their depressive symptoms (t = −2.57,
p = 0.01), perceived social support from others (t = −2.06, p = 0.04), and
optimism (t = 2.29, p = 0.02). The analysis also showed that female patients higher
score on BDI and perception of social support from others, and lower scores in optimism
than male patients.

To examine the differences in psychological factors in relation to working status,
one-way ANOVA was conducted. The analysis showed that there was a significant difference
in depressive symptoms, and perceived social supports from family in regards to
working status, (F3,806 = 9.3, p < 0.05, F3,806 = 3.1, p <
0.05, respectively). Using post hoc comparison (scheffe), the analysis showed that
that those who are not working (M =17.8, SD = 10.5) were significantly different
(higher mean) in their BDI score from those working full time (M =13.5, SD = 8.9).
Also those who are not working (M = 22.5, SD = 5.1) were significantly different
(higher mean) in their perception of social support from family those who had part-time
job (M = 20.6, SD = 5.0). Regarding the other factors than include perceived social
support from others and friends, optimism, life satisfaction, coping and psychological
distress, the analysis showed that there are no differences between patients scores
related to their working status (p > 0.05).

hoc comparison showed that patients who are diagnosed with CVD (M = 21.8, SD = 5.4)
are significantly different (lower mean score of perception) from those diagnosed
with DM-II (M = 23.4, SD = 4.3). Related to perceived social support from family
(F5,806 = 4.6, p < 0.05), post hoc comparison showed that patients who
are diagnosed with cancer (M = 23.4, SD = 3.8) are significantly different (higher
mean score of perception) that patients diagnosed with pulmonary disease (M = 21,
SD = 4.9), and patients diagnosed with DM-II (M = 23, SD = 4.3) are significantly
different (higher mean score of perception) that patients diagnosed with CVD (M
= 21.3, SD = 5.4). Related to perceived social support from friends (F5,806
= 5.9, p < 0.05), post hoc analysis revealed that people with co-morbid diseases
(M = 16.5, SD = 6.8) are significantly different (lower mean score of perception)
from those diagnosed with CVD (M = 17.3, SD = 6.2), and RA (M = 19.6, SD = 5.6).
This indicates that patients who are suffering from more than one chronic disease
had lower perception, in general, than those who are diagnosed with one chronic
illness. In regard to optimism, the analysis also revealed significant differences
between patients related to their medical diagnosis (F5,806 =5.3, p <
0.05). Post hoc test showed that patients diagnosed with cancer (M = 32.3, SD =
6.4) are significantly different (had lower mean score of optimism) from those diagnosed
with RA (M = 35.1, SD = 5.1) and DM-II (M = 35.7, SD = 5.6). Regarding life satisfaction,
the significant differences (F5,806 = 3.2, p < 0.05), using post hoc
comparison, was between those diagnosed with pulmonary disease (M = 22.7, SD = 6.0)
and those diagnosed with DM-II (M = 24.8, SD = 5.4), with means score of life satisfaction
higher among those diagnosed with DM-II. In relation to the significant difference
between patients related to psychological distress (F5,806 =3.0, p <
0.05), the analysis, using post hoc comparison, was between those diagnosed between
those diagnosed with cancer (M = 45.2, SD = 11.2) and those with DM-II (M = 40.4,
SD = 11.3), with means score of psychological distress of patients diagnosed with
cancer higher than those diagnosed with DM-II.

4. Discussion

Physical health conditions may produce psychological disturbances, and psychological
problems may exacerbate physical condition of individuals diagnosed with chronic
illnesses [1]
[19] . Therefore; screening for psychological factors among patients
diagnosed with chronic illness/s, is considered a primary function for health professional
caring for this group of patients [20] -[22] . This study aimed at examining the psychological and
social health factors among patients diagnosed with chronic illnesses in Jordan.
The study found, in general, that patients diagnosed with chronic illnesses in Jordan
suffer psychological and social disturbances. A significant number of patients (17.5%)
reported having moderate to severe depressive symptoms, and about 50% of them had
high level of optimism and life satisfaction, and moderate level of effectiveness
of coping skills, psychological distress, and perceived social support from family,
friends and others.

Previous international studies aimed at detecting prevalence of psychological disturbances
among patients with chronic illness were controversial. While some studies [23][24] found that
depression was common among patients with chronic illnesses and that incidence of
depression is almost twice among patients with diabetes mellitus, others [25] reported that depressive symptoms was less prevalent
among patients with chronic illnesses than those with acute illnesses. Moreover,
other studies found that chronic illnesses increased the vulnerability to psychological
stressors and psychosocial co-morbidity [1][19] . The results of our study do support
those who found that depressive symptoms are prevalent among patients with chronic
illnesses. However, we have found also that patients were almost optimistic, use
effective coping skills more frequently, and had positive perception of social support.
The results contrast previous reports and add a new understanding to the intercorrelation
between psychosocial factors among patients with chronic illnesses. One possible
explanation is that patients had depressive feeling, however; they have also utilized
available sources of social support and used effective coping skills that might
enabled them to effectively manage these negative symptoms. Another explanation
might be related to the intercorrelation of depressive symptoms and psychological
distress and the use of social support as buffering system. According to Cohen,
Gottlieb and Underwood [26] , social support
influences health through either the stress-buffering model or the main effect model.
The main premises of the stress-buffering model is that others will provide necessary
resources that may redefine the potential for harm posed by a situation and cushions
one’s perceived ability to cope with imposed demands, thereby preventing a particular
situation from being perceived as stressful. Supportive beliefs may reduce maladaptive
behaviors. In addition, the main-effect model claims that the individual is under
the influence of social control [26] . These
two models provide an explanation for how an individual’s physical and mental health
is maintained and promoted. The individual’s social support, based on the stress
buffering and main effect models, influences the individual’s emotions, cognition,
and behaviors, and consequently; are able to perceive risk factors and functions
in a healthy way to maintain and promote their health. This may resulted in maintaining
positive levels of optimism, life satisfaction and effectively using coping skills.
The results also support Lewinsohn’s model that patients with chronic illnesses
are at risk for depression if their illness affected their ability to function [27] . In this study, patients were able to maintain
their function utilizing psychological and social support that, in turn; resulted
in improving their life satisfaction and optimistic view of their life. In conclusion,
Jordanian patients with chronic illness are suffering psychological and social disturbances,
however; they were able to manage and maintain their functionability that affected
positively their optimistic view of life, their satisfaction about their life and
their ability to use effective coping skills.

This study also found that older patients are more likely to have higher level of
support from friends and others, higher level of life satisfaction, lower level
of support from friends and higher level of psychological distress. Which also corresponds
with our previous explanation that chronicity of illness if not disabled patient
causing significant dysfunction; it will not worsen their psychological status.
Moreover, female patients had higher scores in depression, stress and perceived
social support from family. The results agree with previous studies [24] that female patients had higher scores in depression
than male patients. However, this study is the first to compare six psychosocial
factors among five types of chronic illnesses. This study found that there were
significant differences among the five types of chronic illnesses across the six
psychosocial factors. Particularly, the study found that patients diagnose with
cancer and diabetes mellitus found to be most different than all others patients
groups (arthritis, CVD, and pulmonary diseases). The study results also add that
depressive symptoms and perceived social support from friends were the most psychosocial
factors that seem to be different across the five groups of patients.

One limitation for this study is that data were cross sectional. A longitudinal
study may allow better understanding for a cumulative experience over long period
of time.

5. Conclusions

Psychological disturbances are common in hospitalized patients with chronic illnesses.
This study found that although patients had moderate levels of depression and stress,
patients also had positive optimistic view of their lives and life satisfaction,
able to use effective coping skills, and had positive perceived social support.
Sociodemographic factors and type of illness had also found to be significant factors
in determining the prevalence of psychosocial levels.

The study has an implication for health professionals at the community and primary
care settings. There is a need to assess and screen for psychosocial factors such
as stress, depression, social support, optimism, life satisfaction and coping skills
which are among patients with chronic illness in their routine checkups and visits
to outpatients units. There is also a need to develop large treatment trials aimed
at improving outcomes of psychosocial wellbeing in medical illnesses to prospect
the cost and burden of such illnesses. Sociodemographic factors and type of illness
should also be taken into account in planning future studies as well as screening
and intervention programs.

References

Doumit, J. and Nasser, R. (2010) Quality of Life and Wellbeing of the Elderly in
Lebanese Nursing Homes. International Journal of Health Care, 23, 72-93.

Rozanski, A., Blumenthal. J.A., Davidson,
K.W., Saab, P.G. and Kubzansky, L. (2005) The Epidemiology, Pathophysiology, and
Management of Psychosocial Risk Factors in Cardiac Practice: The Emerging Field
of Behavioral Cardiology. Journal of the American College of Cardiology, 45, 637-651.
http://dx.doi.org/10.1016/j.jacc.2004.12.005

Cohen, S., Underwood, L.G. and Gottlieb,
B.H. (2000) Social Relationships and Health. In: Cohen, S., Underwood, L.G. and
Gottlieb, B.H., Eds., Social Support Measurement and Intervention: A Guide for Health
and Social Scientists, Oxford University Press, New York.